1548448186 NPI number — TENNILLE L LEFTWICH PA-C

Table of content: TENNILLE L LEFTWICH PA-C (NPI 1548448186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548448186 NPI number — TENNILLE L LEFTWICH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEFTWICH
Provider First Name:
TENNILLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548448186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3901 W 15TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75075-7738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-562-1265
Provider Business Mailing Address Fax Number:
469-484-0648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3901 W 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-7738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-562-1265
Provider Business Practice Location Address Fax Number:
469-484-0648
Provider Enumeration Date:
02/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  PA05559 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA05559 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 174014100 . This is a "FIRST CARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00629320 . This is a "MEDICARE RAIL ROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 193513201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8Y3719 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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